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Open Access Research article

Listening to diverse community voices: the tensions of responding to community expectations in developing a male circumcision program for HIV prevention in Papua New Guinea

Anna Tynan1*, Peter S Hill1, Angela Kelly23, Martha Kupul3, Herick Aeno3, Richard Naketrumb3, Peter Siba2, John Kaldor4, Andrew Vallely24 and for the Male Circumcision Acceptability and Impact Study (MCAIS) team

Author Affiliations

1 Australian Centre for International & Tropical Health, School of Population Health, University of Queensland Herston Road, Herston, 4006 Queensland, Australia

2 Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research (PNG IMR), Eastern Highlands Province 441, P.O. Box 60, Goroka, Papua New Guinea

3 International HIV Research Group, School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia

4 Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, 2034 New South Wales, Australia

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BMC Public Health 2013, 13:749  doi:10.1186/1471-2458-13-749

Published: 13 August 2013

Abstract

Background

The success of health programs is influenced not only by their acceptability but also their ability to meet and respond to community expectations of service delivery. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have recommended medical male circumcision (MC) as an essential component of comprehensive HIV prevention programs in high burden settings. This study investigated community-level perceptions of MC for HIV prevention in Papua New Guinea (PNG), a setting where diverse traditional and contemporary forms of penile foreskin cutting practices have been described.

Methods

A multi-method qualitative study was undertaken in four provinces in two stages from 2009 to 2011. A total of 82 in-depth interviews, and 45 focus group discussions were completed during Stage 1. Stage 2 incorporated eight participatory workshops that were an integral part of the research dissemination process to communities. The workshops also provided opportunity to review key themes and consolidate earlier findings as part of the research process. Qualitative data analysis used a grounded theory approach and was facilitated using qualitative data management software.

Results

A number of diverse considerations for the delivery of MC for HIV prevention in PNG were described, with conflicting views both between and within communities. Key issues included: location of the service, service provider, age eligibility, type of cut, community awareness and potential shame amongst youth. Key to developing appropriate health service delivery models was an appreciation of the differences in expectations and traditions of unique cultural groups in PNG. Establishing strong community coalitions, raising awareness and building trust were seen as integral to success.

Conclusions

Difficulties exist in the implementation of new programs in a pluralistic society such as PNG, particularly if tensions arise between biomedical knowledge and medico-legal requirements, compared to existing socio-cultural interests. Community participatory approaches offer important opportunities to explore and design culturally safe, specific and accessible programs.

Keywords:
Community participation; Male circumcision; Penile cutting; HIV